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WarringtonSafeguarding Children Board Procedures Manual

Female Genital Mutilation

Local Information

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Acknowledgements

The Pan Cheshire Safeguarding Children and Adult Boards would like to thank Wirral Safeguarding Children Board/Safeguarding Adult Partnership Board for allowing the adaptation of their protocol for local use. This guidance is new and was added to the procedures manual in December 2016.

Contents

  1. Introduction
  2. What is FGM?
  3. Types of FGM
  4. Who Practices FGM?
  5. Health Impact of FGM
  6. Risk Factors
  7. Protective Legislation
  8. Identifying FGM
  9. Procedure Within Social Care for Safeguarding Children, and Adults at Risk
    1. Representation at Strategy Meetings
    2. Agenda for Strategy Meetings
  10. Assessment
  11. Procedure for Safeguarding Children and Adults from FGM within Education / Leisure and Community and Faith Groups, including Non-Statutory Organisations
  12. Procedure for Safeguarding Children and Adults from FGM within the Health Sector
  13. Procedures for Police Officers/Police Staff
  14. When an Adult Female has Undergone/is about to Undergo FGM
  15. Appendix 1: Guidance for Interviewing Parents/Children/Adults at Risk
  16. Appendix 2: Legislation on Female Genital Mutilation
  17. Appendix 3: Useful Contacts
  18. Appendix 4: Related Guidance
  19. Appendix 5: Glossary
  20. Appendix 6: Decision-Making and Action Flowchart for Safeguarding Adults at Risk
  21. Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM
  22. Appendix 8: Decision-Making and Action Flowchart for Safeguarding Children - Actual FGM
  23. Appendix 9: Flowchart for General Practice Staff

1. Introduction

The Local Safeguarding Children and Adults Boards across Cheshire recognise that FGM has been carried out for centuries, and it directly causes serious short and long term medical and psychological complications. Consequently it is considered to be a physically abusive act.

This practice guidance covers female children under the age of 18 and adult females including those who come under the Care Act 2014 definition of an Adult at risk (see Appendix 5: Glossary). These groups of females will have similar needs for support and protection but different legislation and routes to safety will apply.

To prevent FGM in the future, agencies need to work closer with practising communities and foster stronger links so together we are able to break the taboo and silence surrounding the harmful practice of FGM.

2. What is FGM?

The World Health Organisation (WHO) states that female genital mutilation (FGM):

“Comprises of all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.”

WHO Fact sheet No. 241 (February 2014)

FGM is also known as Female Circumcision (FC) and Female Genital Cutting (FGC). These alternative definitions are better received in the communities that practice it, who do not see themselves as engaging in mutilation. There are also other terms used to describe these practices in different countries across the world).

FGM is included within the revised (2013) government definition of Domestic Violence and Abuse.

Additional information about FGM can be found in Multi-Agency Statutory Guidance on Female Genital Mutilation (Home Office, 2016).

3. Types of FGM

  1. 'Clitoridectomy which is the partial or total removal of the clitoris and, in rare cases, the prepuce (the fold of skin surrounding the clitoris);
  2. Excision which is the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the 'lips' that surround the vagina); Type 1 and II account for 75% of all worldwide procedures;
  3. Infibulation which is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris; Type III accounts for 25% of all worldwide procedure and is the most severe form of FGM;
  4. All other types of harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

4. Who Practices FGM?

FGM is practised around the world in various forms across all major faiths. It has been estimated that currently, about three million girls, most of them under 15 years of age, undergo the procedure every year. The majority of FGM takes place in 29 African and Middle Eastern countries, BUT includes other parts of the world; Asia, and in industrialised nations through migration which includes; Europe, North America, Australia and New Zealand. Globally the WHO estimates that between 100 and 140 million girls and women worldwide have been subjected to one of the first three types of FGM.

There are substantial populations of people in the UK from countries where FGM is endemic; in London, Liverpool, Birmingham, Sheffield, Cardiff and Manchester (HM Government 2006). UK communities that are most at risk of FGM include Kenyans, Somalis, Sudanese, Sierra Leoneans, Egyptians, Nigerians, Eritreans and Ethiopians. However women from non-African communities that are at risk of FGM include Yemeni, Kurdish (Iraqi, Iranian and Turkish country of origin), Indonesian, Malaysian, Pakistani women and Indian women (Muslim Bohra Community).

It is important to recognise that the migrant populations may not practice FGM to the same level as their country of origin; a migrant's reason for being in the UK may well be avoidance of FGM and second and third generation migrant populations may have very different attitudes towards FGM than their parents. However despite their differing attitude towards FGM, this second or third generation may be the children or adults at greatest risk of having the procedure carried out.

5. Health Impact of FGM

FGM has NO health benefits, and causes harm in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies. Many women appear to be unaware of the relationship between FGM and its health consequences; in particular the complications affecting sexual intercourse and childbirth which can occur many years after the mutilation has taken place.

5.1 Health Complications Are Common and Can Lead to Death

The highest maternal and infant mortality rates are in FGM-practising regions. The actual number of girls who die as a result of FGM is not known. However, in areas of Sudan where antibiotics are not available, it is estimated that one-third of the girls undergoing FGM will die.

 

6. Risk Factors

  • The family comes from a community that is known to practice FGM;
  • Any female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other female children in the extended family;
  • Any female who has a relative who has already undergone FGM must be considered to be at risk;
  • The socio-economic position of the family and the level of integration within UK society can increase risk.

7. Protective Legislation

See also Appendix 2: Legislation on Female Genital Mutilation.

FGM has been a criminal offence in the UK since The Prohibition of Female Circumcision Act 1985. The Act was repealed by The Female Genital Mutilation Act 2003.

The Serious Crime Act 2015 strengthened the legislative framework around tackling FGM. The Act introduced 'habitual UK resident' rather than 'permanent UK resident', and introducing FGM Protection Orders (similar to Forced Marriage Protection Orders).

FGM is considered to be a form of child abuse (it is categorised under the headings of both Physical Abuse and Emotional Abuse). A local authority may exercise its powers under Section 47 of the Children Act 1989 if it has reason to believe that a child is likely to suffer or has suffered FGM. Under the Children Act 1989, local authorities can apply to the Courts for various Orders to prevent a child being taken abroad for mutilation.

FGM is also an abuse of female adults usually categorized under honour based violence and domestic abuse definitions. Where a female adult is also defined as an Adult at Risk, additional support mechanisms would be available through local social care teams and adult safeguarding processes.

Private law remedies can be used as a form of legal protection. For example a Prohibited Steps Order under Section 8 Children Act 1989 can be used to prevent a child being taken abroad or from having the procedure. A Non Molestation Order under Part IV of the Family Law Act 1996 may also be used as protection for the child or adult. The Domestic Violence Crime and Victims Act 2004 make the breach of a Non Molestation Order a criminal offence.

It may be possible for victims of FGM to claim compensation from the Criminal Injuries Compensation Authority. The injuries must be reported to the police.

The Police have Police Protection powers where there is reasonable cause to believe that a child or young person, under the age of 18 years, is at risk of Significant Harm. A police officer may (with or without the cooperation of social care) remove the child from the parent and use the powers for 'police protection' (section 46 of the Children Act 1989) for up to 72 hours.

The Local Authority has further powers under Section 44 of the Children Act 1989. Under this section, the Local Authority may apply for an Emergency Protection Order (EPO). The Order authorizes the applicant to remove the girl and keep her in safe accommodation for up to 8 days. This Order is often sought to ensure the short term safety of the child.

An EPO can be followed by an application from the Local Authority for a Care Order, Supervision Order or an Interim Order (sections 31 and 38 of the Children Act 1989). Without such an application, the EPO will lapse and the local authority will no longer have Parental Responsibility for the child.

There will be cases where a Care Order is not appropriate, possibly because of the age of the young person. A Local Authority may ask the Court to exercise its inherent jurisdiction to protect the young person.

Once a young person has left or been removed from the jurisdiction, the options available to police, Local Authority and other services become more limited. In such situations an application may be made to the High Court to make the young person a Ward of Court and have them returned to the UK.

When a British national seeks assistance at a British Embassy or High Commission overseas and wishes to return to the UK, the Foreign and Commonwealth Office (FCO) will do what it can to assist or repatriate the individual.

International legislation

There are two international conventions containing articles which can be applied to FGM. Signatory states, including the UK, have an obligation under these standards to take legal action against FGM. These include: The UN Convention on the Rights of the Child and The UN Convention on the Elimination of All Forms of Discrimination against Women. FGM breaches several of these rights.

8. Identifying FGM

There are three circumstances relating to FGM which require identification and intervention:

  • Where a girl / woman is at risk of FGM;
  • Where a girl / woman has undergone FGM;
  • Where a prospective mother has undergone FGM.

Professionals and volunteers in most agencies have little or no experience of dealing with female genital mutilation. Encountering FGM for the first time can cause people to feel shocked, upset, helpless and unsure of how to respond appropriately to ensure that a child, and/or a mother/any female adult, is protected from harm or further harm. The following agency specific guidance may help support the professional.

8.1 When a girl / woman is at risk of FGM

Indicators that FGM may soon take place:

  • Parents state that they or a relative will take the child out of the country for a prolonged period;
  • A child may talk about a long holiday (usually within the school summer holiday) to her country of origin or another country where the practice is prevalent;
  • A child may confide to a professional that she is to have a 'special procedure' or to attend a special occasion;
  • A professional hears reference to FGM in conversation, for example a child may tell other children about it.

8.2 Where a girl / woman has undergone FGM

Signs that FGM has taken place:

  • Prolonged absence from school with noticeable behaviour changes on the girl's return;
  • Longer/frequent visits to the toilet at any time, but particularly after a holiday abroad;
  • Some girls may find it difficult to sit still and appear uncomfortable or may complain of pain between their legs;
  • Some girls may speak about 'something somebody did to them, that they are not allowed to talk about';
  • A professional overhears a conversation amongst children about a `special procedure' that took place when on holiday;
  • Young girls refusing to participate in P.E regularly without a medical note;
  • Recurrent Urinary Tract Infections (UTI) or complaints of abdominal pain.

8.3 Where a prospective mother has undergone FGM

Routine questioning for FGM is now incorporated into antenatal care. However, all professionals in all agencies should be alert to the risks of FGM and recognise the opportunity during the antenatal period to explore this with the pregnant women.

If you identify a female under 18 has had FGM you have a duty under the Serious Crime Act (2015) to report this to the Police via the non emergency number 101.

Any information or concern that a child (including unborn) or an Adult at Risk is at risk of, or has undergone, FGM MUST ALSO result in a safeguarding referral to the Local Authority Social Care department following the usual procedure for your area. If there is immediate danger, call 999.

9. Procedure Within Social Care for Safeguarding Children and Adults at Risk

Professionals should make a safeguarding referral in accordance with their local procedures. If a professional feels that a child is at risk of immediate significant harm they should not discuss the referral with the parents/carers/family until a Strategy meeting has been convened

The initial referral to Children's social care should be treated as a Child Protection referral and an immediate strategy discussion should be held to determine immediate safeguards required to protect the child. A multi agency Strategy Meeting must be called within two working and chaired by a Senior Social Care representative. The Strategy Meeting must consider the risks of FGM to all children in the household. In situations where the referral relates to an unborn the Pre-Birth assessment must be completed prior to birth and ideally started at 26 weeks. The pre-birth assessment must consider the mothers views on FGM and her partners and extended family members views on FGM in order to determine the risks presented to the child upon birth.

Each agency involved in the multi-agency strategy meeting must share relevant information that their agency holds, which will contribute to the multi-agency plan and investigation required to safeguard the child/women. During this period agencies should continue to look for appropriate support for the Child/women in order to address any emotional/physical harm caused as a consequence of the FGM or prospect of FGM.

If a referral is received concerning one female in a family, consideration must be given to whether other females in that family are also at similar risk. There should be consideration of other females from associated families once concerns are raised about an incident or the perpetrator of FGM.

See Appendix 3: Useful Contacts.

See also Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM.

9.1 Representation at the Strategy Meeting

Professionals in attendance at the strategy meetings must include (as a minimum) appropriate representation from:

  • Children's Social Care;
  • Cheshire Police;
  • Appropriate health processional; and
  • Any other professional deemed appropriate according to the individual case.

9.2 Agenda for Strategy Meeting

The FGM Strategy Meeting should cover, at a minimum, the following issues:

  • Family history and background information;
  • Establish whether parents or the girl/woman has had access to information about the harmful aspects of FGM and the law in the UK. If not this information should be made available to them;
  • Scope of the investigation, what needs to be addressed and who is best placed to do this;
  • Roles and responsibilities of individuals and organisations within the investigation, with particular reference to the role of the police;
  • Whether a medical examination/treatment is required (including therapeutic services) and, if so, who will carry out what actions, by when and for what purpose. An identified professional should contact SARC for guidance and advice;
  • Establish whether the case meets the criteria for mandatory reporting and agree which agency will do this;
  • What action may be required if attempts are made to remove the child / adult from the country;
  • Identify key outcomes for the child/adult and their family and implications and impact on the wider community.

Regulated professionals i.e. teachers, social workers and healthcare professionals have a duty under the Serious Crime Act (2015) to report any cases of FGM identified in a female under 18 years of age to the police via the non-emergency number: 101.

10. Assessment

Where a female has been identified as at risk or has had FGM, it may not be appropriate to take steps to remove the child or Adult at Risk from an otherwise loving family environment. Experience has shown that often the parents themselves can experience pressure to agree to FGM and see it as the best thing they can do for their daughter's marriageable status. It is also important to recognise that those seeking to arrange the mutilation are unlikely to perceive it to be harmful and, on the contrary, believe it to be legitimised by longstanding traditions. Therefore it is essential that when first approaching a family about the issue of FGM a thorough assessment should be undertaken, with particular focus on:

  • Parental/carer attitudes and understanding about the practice and where appropriate;
  • Child/young person/Adult at Risk's knowledge, understanding and views on the issue;
  • For an Adult at Risk a Capacity assessment will be required to see whether the legislation of the Mental Capacity Act 2005 applies;
  • Consideration of whether there are any issues relating to domestic abuse.

Every attempt should be made to work with parents/carers on a voluntary basis to prevent abuse. It is the responsibility of the multi agency partnership to look at every possible way that parental/family co-operation can be achieved. However, the child's/adult's best interest is always paramount, and as a result, any indication of increased risk of the procedure taking place should be responded to swiftly.

Some thought and consideration should be given to where the assessment is undertaken. For example it may be beneficial to talk to the family/affected female outside the home environment to encourage them to talk freely and acknowledge the impact FGM would have.

An interpreter must be used in all interviews with the family, especially the affected female, if their first language is not English. The interpreter must not be a family relation and must not be known by the family. The interpreter should be female. In cases where an interpreter is not used and English is not the female's first language, the reasons for not using an interpreter must be recorded, as part of the assessment.

Appropriate communication aids must be offered for affected females who have difficulties communicating due to disability/illness and this should be documented within the record.

All interviews should be undertaken in a sensitive manner, and should only be carried out once.

With regards to children - parental consent and the child's agreement should be sought before interviews take place. All attempts must be made to work in partnership with parents; where consent is not given, legal advice should be sought. Children of sufficient age and understanding should be given every opportunity to be interviewed alone.

Adults who are vulnerable / At Risk need to be interviewed alone and a Capacity assessment completed. Capacity is a decision and time specific - the decisions to be assessed may include whether they can consent to travel abroad when there is a risk of their family arranging for them to undergo FGM. If they are not able to make a decision or safeguard themselves, then a Best Interests decision should be made. When an adult lacks Capacity and needs to be safeguarded the Local Authority can apply to the Court of Protection to give them powers to protect an individual. Adults at Risk who are assessed as having Capacity but are at risk of coming to harm can be protected using the powers contained within the inherent jurisdiction of the high court. Other adults may be protected for example through non molestation orders.

The Strategy Meeting should reconvene as agreed to discuss the outcomes and recommendations from the initial investigations and assessment. The multi agency group will need to agree next steps for support and level of need.  At all times the primary focus is to prevent the female undergoing any form of FGM by working in partnership with parents, carers and the wider community to address risk factors. However where the assessment identifies a continuing risk of FGM then, the first priority is protection and the local authority should consider the need for:

  • Legal action;
  • Criminal prosecution;
  • An Initial Child Protection Case Conference/Adult Safeguarding Conference.

If a Child Protection Conference is deemed necessary and a Child Protection Plan is to be formulated, the Category of Abuse should be Physical Abuse.

For Adults, a Safeguarding Plan will be formulated and monitored in accordance with the Local Safeguarding Adult Board Procedures (See Appendix 6: Decision-Making and Action Flowchart for Safeguarding Adults at Risk).

Following all enquiries into FGM, regardless of the outcome, consideration must be given to the therapeutic/counselling needs of the female and the family.

Medical examination, if necessary must only be undertaken with the child's and the parents' consent or the consent of the adult female. If the adult lacks the Capacity to consent to the examination; then a Best Interests decision can be made for them. Where parents do not consent, legal advice should be sought.

In the majority of cases there should only be one medical examination of the child or woman. In cases where subsequent medicals are required, clear reasons for this decision should be recorded as part of the assessment.

If a medical/surgical procedure is required, and parents refuse consent, legal advice must be sought immediately.

Children in Immediate Danger

Where the child appears to be in immediate danger of FGM and parents cannot satisfactorily guarantee that they will not proceed with it, and then an Emergency Protection Order should be sought.

Adults in Immediate Danger

When an adult is in immediate danger, contact the police. If concerned, irrespective of whether the adult has capacity or not, take legal advice as applications to either the Court of Protection or High Court may be required.

If there is no evidence of risk to the Adult at Risk or Child (ren)

If the safeguarding enquiry concludes that there is no clear evidence of risk to the female then Social Care will:

  • Consult the female's GP and a child's Health Visitor or School Nurse about this conclusion and invite her/him to notify Social Care if any further information challenges it;
  • Notify appropriate professionals involved with the family of the enquiry and the stage at which it was concluded;
  • Inform the family and the referrer that the enquiry has been concluded;
  • Consider whether any child may be a Child in Need or if the adult requires a community care assessment and, if so, offer appropriate services and offer the family/carers any appropriate support services.

11. Procedure for Safeguarding Children and Adults from FGM within Education / Leisure and Community and Faith Groups

See also Keeping Children Safe in Education (DfE, March 2015).

Teachers, other school staff, volunteers and members of community groups may become aware that a female is at risk of FGM) through a parent / other adult, a child or other children disclosing that:

  • The procedure is being planned;
  • An older child or adult in the family has already undergone FGM.

A professional, volunteer or community group member who has information or suspicions that a female is at risk of FGM should consult with their agency or group's designated safeguarding adviser (if they have one) and should make an immediate Referral to children's social care in accordance with their local safeguarding procedures.

The Referral should not be delayed in order to consult with the designated safeguarding adviser, a manager or group leader, as multi-agency safeguarding intervention needs to happen quickly.

Once concerns are raised about FGM there should also be consideration of possible risk to other females in the practicing community.

Regulated professionals i.e. teachers, social workers and healthcare professionals have a duty under the Serious Crime Act (2015) to report any cases of FGM identified in a female under 18 years of age to the police via the non-emergency number: 101.

12. Procedure for Safeguarding Children and Adults from FGM within the Health Sector

Health professionals in GP surgeries, sexual health clinics, Women's Health, A&E and maternity services are the most likely to encounter a girl or woman who has been subjected to FGM. All girls and women who have undergone FGM should be given information about the legal and health implications of practicing FGM. Health Professionals should remember that some females may be traumatised from their experience and have already resolved to never allow their daughters to undergo this procedure.

Mandatory recording and reporting for Healthcare providers

Healthcare professionals have a duty under the Serious Crime Act (2015) to report any cases of FGM identified in a female under 18 years of age to the police via the non-emergency number: 101.

It is mandatory for health professionals to record the presence of FGM in a patient's healthcare record whenever it is identified through the delivery of NHS healthcare. The patient's health record should always be updated with whatever discussions or actions have been taken. If the patient has had FGM, referral to a specialist FGM clinic should always be considered. In addition to any referral to social care and / police.

In maternity departments it should be part of routine enquiry to ask women whether they have undergone FGM. However FGM may be identified in many other clinical settings, including family planning clinics, sexual health services, obstetrics & gynaecology, General Practice, Accident & Emergency, mental health services. In all circumstances staff must act upon warning signs such as a history of repeat urinary tract infections, a planned holiday to countries / areas of high prevalence for a girl to undergo a special ceremony, or a family history of FGM.

If a patient is identified as being at risk of FGM this information must be shared with the GP and Health Visitor or School Nurse (dependent on the child's age), as part of child safeguarding actions.

Since April 2014, it is be a mandatory requirement for NHS hospitals to record:

  • If a patient has had FGM;
  • What type of FGM;
  • If there is a family history of FGM;
  • If an FGM-related procedure has been carried out on a women - (deinfibulation).

Since September 2014, all acute hospitals have reported this data via the FGM Enhanced Dataset. From 1st October 2015 this same duty extended to include Mental Health Trusts and GP practices. This is part of a wide ranging programme of work by the Department of Health to improve the way in which the NHS will respond to the health needs of girls and women affected by FGM.

It will need to be determined locally how the collection of information to support the FGM Enhanced Dataset will be managed, including any data capture mechanisms. Healthcare providers are encouraged to consider an implementation plan across their organisation, which considers what steps, can be taken to monitor reporting compliance.

GPs, and Practice Nurses

GPs and Practice Nurses should be vigilant to any health issues such as resistance to partake in cervical smear testing. When a female attends the practice presenting with symptoms related to urology/gynaecology/sexual health problems you must specifically ask about FGM and the pathway in Appendix 9: Flowchart for General Practice Staff followed. In addition consider asking those that attend for health checks or travel vaccinations from affected communities about FGM and advising on the health impacts.

In accordance with the mandatory reporting requirements; the GP/Nurse should document in the patients record:

  • If a patient has undergone FGM;
  • What type of FGM;
  • If there is a family history of FGM;
  • If any FGM-related procedure has been carried out on a women - (including deinfibulation).

Further clarification questions (see Appendix 1: Guidance for Interviewing Parents/Children/Adults at Risk) should be asked to determine if there are any safeguarding issues. The FGM Risk Assessment Guidance found in the Female Genital Mutilation Risk and Safeguarding Guidance for Professionals (DoH), will help to determine the most appropriate referral pathway. They should be offered/referred for additional support. Document in the record any advice or leaflets that are provided. Professionals should follow the “What to do if you are concerned about a child flowchart”, contact the Named and Designated professionals for advice if required and make a referral to Children's Social Care where there are safeguarding concern

In all cases of FGM identified (irrespective of age or whether there are safeguarding issues identified or not), the information should be submitted via the FGM template (distributed to GP practices), to the Named GP for Safeguarding Children who will ensure the practice receive support if required and will upload the data to the FGM Enhanced Dataset

Midwives and nurses should be aware of how to care for women and girls who have undergone FGM during the antenatal, intrapartum and postnatal periods. They should discuss FGM at the initial booking visit to all women. They should document if the woman has:

  • Undergone FGM;
  • What type of FGM;
  • If there is a family history of FGM;
  • Has an FGM-related procedure has been carried out on a women - (including deinfibulation).

They must also document what plan is in place for delivery. It should be documented that the woman has been told about the health risks and the law and given a leaflet in an appropriate language (if available) that explains the health risks of FGM, the law and local support services. All this information should be shared with appropriate health professionals (including the GP and the Health Visitor). Professionals should consult with their safeguarding leads for guidance and support

Re-infibulation is illegal in the UK. If a girl or woman who has been de-infibulated requests re-infibulation/re-suturing after the birth of a child, and/or the child is female or there are daughters in the family, health professionals should consult with their safeguarding leads and with Children's Social Care to ensure a referral has been made.

Whilst the request for re-infibulation is not in itself a safeguarding issue, the fact that the girl or woman is apparently not wanting/able to comply with UK law due to family pressure and / or does not consider that the procedure is harmful raises concerns in relation to female children she may already have or may have in the future.

Some women may be pressured to ask for re-infibulation by their partner. This would come under the category of Domestic Violence and Abuse and local protocols must be followed.

Health visitors are in a good position to reinforce information about the health consequences and the law relating to FGM. Health visitors should discuss the risks of FGM and document the parent's response and the advice and any leaflets given to explain the law relating to FGM. Any concerns about a parent's attitude towards FGM should be taken seriously and appropriate referrals made. Professionals should consult with their safeguarding leads about making a referral to social care and inform the family's GP of the referral.

School Nurses are in a good position to reinforce information about the health consequences and the law relating to FGM. The school nurse should work closely with the child's school supporting them with any concerns, and be vigilant to any health issues such as recurrent urinary tract infection that may indicate FGM has been undertaken. If the school nurse has contact with any family that originates from a country where FGM is practised, they should discuss the risks of FGM and document the parent's response along with any advice and leaflets provided to explain the law relating to FGM. Any concerns about a parent's attitude towards FGM should be taken seriously and appropriate referrals made.

Mental Health Practitioners need to be aware of the risks associated with FGM if girls/women from FGM practising countries attend, particularly with Post Traumatic Stress Disorder for example. If a disclosure is made regarding FGM, this should be documented and professionals should consult with their child or adult safeguarding lead about the appropriate course of action.

Emergency Departments and Walk-in Centres need to be aware of the risks associated with FGM if girls/women from FGM practising countries attend, particularly with urinary tract infections (UTIs), menstrual pain, abdominal pain, or altered gait for example. Their assessment should include consideration of the risks associated with FGM. This should be documented and professionals should consult with their child or adult safeguarding lead about making a referral to social care.

Health Services for Asylum Seekers & Refugees: Where initial health assessments for asylum seekers and refugees are undertaken, the health professional can introduce a discussion about FGM. They should document if the female has undergone FGM and what type. They must also document that the woman has been told about the law and given a leaflet in an appropriate language (if possible) that explains the risks of FGM, the law and local support services. All this information should be shared with appropriate health professionals (GP, Health Visitor etc). Professionals should consult with their safeguarding lead about making a referral to Social Care.

13. Procedures for Police Officers/Police Staff

See also Referrals Procedure.

From 31st October 2015 it is a legal requirement that any case of FGM in those under 18 years old is reported to the Police via the 101 non-emergency number.

This may mean that the police are the first point of contact and they should follow the agreed local pathway for referral to Children's Social Care (see Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM and Appendix 8: Decision-Making and Action Flowchart for Safeguarding Children – Actual FGM).

There is a risk that the fear of prosecution of family members may prevent those concerned from seeking help and support from relevant agencies and in particular medical help as a result of long term complications caused by FGM.

In many communities where the practice of FGM is prevalent, children who may have undergone/be due to undergo FGM may accept it as part of their religious/cultural upbringing due to a lack of understanding of the potential criminal offence being committed and future health complications that may prevail.

Police should work with other agencies to obtain relevant support and guidance for the victim. Where relevant they can work with other professionals to prevent FGM by educating parents/carers about the legislation relating to FGM and possible consequences.

Police staff working with Children - If a girl is at risk of undergoing or has already undergone FGM, the duty inspector must be made aware and support should be sought from the Public Protection Investigation Unit where the victim resides or in their absence the CID. Relevant safeguards should be put in place immediately in order to prevent any risk of harm to the child.

Risks to any other children should be considered and acted upon immediately. The investigation should be dealt with as a child safeguarding issue taking cognisance of any honour-based violence issues.

If any officer believes that the girl could be at immediate risk of Significant Harm, they should consider the use of Police Protection powers under section 46 of the Children Act 1989.If it is believed or known that a girl has undergone FGM, a Strategy Meeting must be held as soon as practicable, and dependent upon urgency, to discuss the implications for the child and the coordination of the criminal investigation.

A second Strategy Meeting (if required) should take place within the timeframe agreed at the initial Strategy Meeting.

Children and young people should be interviewed under the relevant procedure/guidelines (e.g. Achieving Best Evidence) to obtain the best possible evidence for use in any prosecution.

Where a medical examination is deemed necessary it should be conducted by a doctor trained in identifying FGM. If it has been decided at the strategy meeting that a safeguarding medical is required an identified professional must contact St Mary's SARC for further advice and guidance. This is to ensure that a holistic assessment which explores any other medical, support and safeguarding needs of the girl or young woman is offered and that appropriate referrals are made as necessary.

14. When an Adult Female has Undergone/is about to Undergo FGM

If an adult female is at risk of undergoing or had already undergone FGM, these incidents should be dealt with by the Public Protection Investigation Unit as a form of Domestic Violence and Abuse/Honour Based Violence incident. Relevant risk assessments (such as the domestic abuse risk indicator checklist) and safeguards should be put in place and referrals to partner agencies made as appropriate in order to ensure the victim receives all relevant support.

If the adult female is an Adult at risk, the adult safeguarding process should be initiated and an urgent Strategy Meeting arranged. Note however if the adult has Capacity and does not give consent the safeguarding process would not be taken forward unless there was a wider 'public interest' element to the case. Immediate protection may be secured through the Court of Protection or the High Court.

Part of the investigation should entail identification of any persons who seek to aide, abet or procure someone to commit FGM and with a view to identifying other victims. Early Crown Prosecution investigative advice will be sought by the Police under the FGM Protocol between Cheshire Constabulary and CPS Mersey-Cheshire Dec 2013.

Appendices

Appendix 1: Guidance for Interviewing Parents/Children/Adults at Risk

Appendix 2: Legislation on Female Genital Mutilation

Appendix 3: Useful Contacts

Appendix 4: Related Guidance

Appendix 5: Glossary

Appendix 6: Decision-Making and Action Flowchart for Safeguarding Adults at Risk

Appendix 7: Decision-Making and Action Flowchart for Safeguarding Children at Risk of FGM

Appendix 8: Decision-Making and Action Flowchart for Safeguarding Children - Actual FGM

Appendix 9: Flowchart for General Practice Staff